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Participant's (child) name:

Gender:

Male
Female
Non-binary / third gender

Age:

Has your child participated in the Stony Brook Rooftop Farm nutrition workshops in the past?

Yes
No

Phone number (home or mobile)

Home address:

List any dietary restrictions:

List any food allergies:

Name of parent/guardian

Email address:

Emergency contact (include full name, phone number & relationship to participant)

Indicate who is authorized to pick up your child from the program (include full name, phone number & relationship to participant)

PAYMENT AND CANCELLATIONS: Payment of $280 is due in full by June 1, 2025. Checks must be made out to: STONY BROOK HEIGHTS ROOFTOP FARM. Food costs, workshop materials, nutrition lessons and culinary instruction are included in the tuition. Registration fees are non-transferable and non-refundable. Payment instructions, waivers and consent forms will be sent to you via email once registration is processed